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  2. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    Nursing documentation is the principal clinical information source to meet legal and professional requirements, care nurses' knowledge of nursing documentation, and is one of the most significant components in nursing care. Quality nursing documentation plays a vital role in the delivery of quality nursing care services through supporting ...

  3. Admission note - Wikipedia

    en.wikipedia.org/wiki/Admission_note

    Admission notes document the reasons why a patient is being admitted for inpatient care to a hospital or other facility, the patient's baseline status, and the initial instructions for that patient's care. Health care professionals use them to record a patient's baseline status and may write additional on-service notes, progress notes ( SOAP ...

  4. Nursing assessment - Wikipedia

    en.wikipedia.org/wiki/Nursing_assessment

    Nursing assessment. Nursing assessment is the gathering of information about a patient 's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.

  5. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization. Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other ...

  6. SAMPLE history - Wikipedia

    en.wikipedia.org/wiki/SAMPLE_History

    SAMPLE history is a mnemonic acronym to remember key questions for a person's medical assessment. [1] The SAMPLE history is sometimes used in conjunction with vital ...

  7. Nightingale Pledge - Wikipedia

    en.wikipedia.org/wiki/Nightingale_Pledge

    Nightingale Pledge. The Nightingale Pledge, named in honour of Florence Nightingale, is a modified version of the Hippocratic Oath. Lystra Gretter and a Committee for the Farrand Training School Grace for Nurses in Detroit, Michigan created the pledge in 1893. Gretter, inspired by the work of Nightingale, the founder of modern nursing, credited ...

  8. Licensed practical nurse - Wikipedia

    en.wikipedia.org/wiki/Licensed_practical_nurse

    A licensed practical nurse ( LPN ), in much of the United States and Canada, is a nurse who provides direct nursing care for people who are sick, injured, convalescent, or disabled. In the United States, LPNs work under the direction of physicians, mid-level practitioners, and may work under the direction of registered nurses depending on their ...

  9. Nursing diagnosis - Wikipedia

    en.wikipedia.org/wiki/Nursing_diagnosis

    A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician ...

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